Management of Bilateral Tension Pneumothorax with Extensive Subcutaneous Emphysema during One-Lung Ventilation

Introduction: Intraoperative complications during thoracic procedures requiring one-lung ventilation (OLV) are rare but life-threatening. Double-lumen endotracheal tubes (DLTs) are commonly used but can lead to complications such as bilateral tension pneumothorax, posing significant challenges for anesthesiologists and thoracic surgeons. This case report highlights a critical incident during a mediastinoscopy under general anesthesia with OLV. Case Presentation: A 43-year-old male with a history of Hodgkin’s lymphoma underwent a mediastinoscopy. Anesthesia induction and intubation with a 37 French Carlen DLT were performed. Shortly after initiating OLV, the patient experienced sudden hypoxemia (SpO2 65%), increased peak airway pressures, bradycardia, and hypotension. Bilateral tension pneumothorax with subcutaneous emphysema was diagnosed, and emergency bilateral chest drain insertion stabilized the patient. Discussion: This case illustrates the severity of DLT-associated complications, particularly tension pneumothorax caused by tube malpositioning and barotrauma. Diagnosing tension pneumothorax is challenging due to similar symptoms with other intraoperative issues. Clinical signs include severe hypoxemia, hypercarbia, hypotension, and increased airway pressures. Rapid diagnosis through chest X-rays and ultrasonography, along with immediate management, such as chest drain insertion, is crucial. Conclusion: The case emphasizes the importance of vigilance and preparedness to manage anesthetic complications during thoracic procedures. Rigorous verification of DLT positioning, continuous monitoring, and prompt interventions are essential to prevent catastrophic events.